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Dr. Ebraheim's educational educational video illustrates the concepts of spine associated with the cervical spine – rheumatoid arthritis. The involvement of the cervical spine occurs in approximately 90% of patients with rheumatoid arthritis. All patients with rheumatoid arthritis should undergo cervical spine examination. Start with x-rays of the cervical spine because this helps diagnose atlantoaxial instability. Early aggressive medical treatment may reduce this risk. C1-C2 instability is common and can occur up to 80%. It occurs due to the transverse ligament pathology. Therefore, you will need to obtain flexion extension views in patients with rheumatoid arthritis, especially preoperative radiographs, and if viewed poorly, should stabilize the spine before performing total hip or total knee elective procedures. Discover the C1-C2 instability and fix it before performing the total elective hip procedure. You see in the X-rays the Atlanto Dental Interval: A.D.I., if it was more than 3.5 mm which means instability of the upper cervical spine may be present. If more than 7 mm means interruption of the alar ligament, these patients may have myelopathy of the cervical spine. The A.D.I. is an unreliable predictor of paralysis. The subsequent atlanto dental interval is a better prediction of the test, it can predict spinal cord injury better. If the later A.D.I. is less than 14 mm, can predict spinal cord injury, get an MRI. Surgery is performed if the A.D.I. is more than 10 mm or if P.A.D.I. is less than 14 mm, the operation is C1-C2 fusion. Clinically: C1-C2 instability could lead to neck pain, headache and myelopathy with abnormal gait, paresthesia and difficulty in fine motor control. Basilar Invagination: They occur in about 40% of patients with rheumatoid arthritis, basilar invagination is superior migration of the odontoid so the tip of the odontoid is above the foramen magnum; in this occipital case to C2 fusion, more or less odontoid resection. Subaxial Subluxation: They occur in about 20% of patients. The indication for surgery is a neurological compromise. The space available for the cord is less than 14 mm and then the posterior fusion surgery is performed; surgery is usually unsuccessful in severe types of neurological disorders. When do you have surgery for rheumatoid arthritis? You do it if there is: • Severe pain • Neurological deficit • X-rays showing that P.A.D.I. is less than 14 mm • Upper odontoid migration • The subaxial subluxation and the diameter of the sagittal duct are less than 14 mm. If the posterior atlanto-dental interval (P.A.D.I.) is greater than 14 mm, the patient will demonstrate a significant motor recovery after surgery.

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